Form Ncui 685-I - Adjustment To Employer'S Quarterly Tax & Wage Report

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Employment Security Commission of North Carolina
Unemployment Insurance Division
Adjustment To Employer’s Quarterly Tax & Wage Report
1. Employer’s Name, Address & Telephone:
2. Account Number (s):_______________________
_________________________________________
________________________
_________________________________________
3. Quarter/Year: ____________________________
_________________________________________
4. Tax Rate: _____________________________%
Contact Person’s Telephone Number:
_________________________________________
FOR AGENCY USE ONLY
Ck Amount
Date
Coll.
Initial
Yes
No
As Reported
As Corrected
5. (A) Wages Paid This Quarter Subject To The Law:
(B)
Less Wages Paid This Quarter In Excess of
$_________ Per Worker This Year:
(C)
Wages Subject To Tax:
6. Tax Paid/Due This Quarter:
7. Additional Tax Due:
8. Interest Due:
9. Penalty - Late Payment Due:
10. Total Due: Check Attached _____ Refund _____
11. (A) Social Security No. (B) Employee’s Name
(C) As Reported
(D) As Corrected
Total
Total
12.
Reason:
13.
This information is true and accurate.
Signed:
Title:
Date:
Form NCUI 685-I (Rev. 2/98)

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